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Abstract: PO1619

Porcine Desiccated Thyroid Extract Associated Dual Positive ANCA Vasculitis

Session Information

Category: Glomerular Diseases

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Kapa, Nandakishor, University of California Davis Medical Center, Sacramento, California, United States
  • Madan, Niti, University of California Davis Medical Center, Sacramento, California, United States
  • Cheng, Mingyu, University of California Davis Medical Center, Sacramento, California, United States
  • Wiegley, Nasim, University of California Davis Medical Center, Sacramento, California, United States
Introduction

Among medications used for thyroid disorders associated with small vessel vasculitis, the most well-known is propylthiouracil. However, there have been no reported cases of ANCA-associated vasculitis (AAV) with desiccated thyroid replacement hormones. We report the first case of drug-induced ANCA vasculitis presumed to be associated with porcine desiccated thyroid supplementation (Armour Thyroid).

Case Description

A 43-year-old Caucasian woman with Hashimoto's thyroiditis and bipolar disorder presenting with 1 month of generalized fatigue, subjective fevers, and foamy urine was found to have acute kidney injury with creatinine (Cr) peaking at 3.80 mg/dL from baseline 1.0 mg/dL. She recently started desiccated thyroid supplementation prior to the onset of symptoms. Urinalysis revealed active sediment with hematuria and subnephrotic proteinuria with 24-hour urine protein 1.1 gm/day. Serologic testing was notable for MPO Ab IgG positive >8.0 AI and PR3 Ab IgG positive > 6.4 AI. Further serologic workup, including anti-histone Ab, was negative. Kidney biopsy revealed features consistent with pauci-immune glomerulonephritis with cellular and fibrocellular crescents, mild interstitial inflammation and tubulitis, and mild arteriosclerosis and hyaline arteriosclerosis. She was not taking any other known medications associated with drug-induced vasculitis. She received pulse dose steroids with taper per the PEXIVAS trial protocol and Rituximab therapy per the RAVE trial protocol. Cr improved (1.6 mg/dL) after induction therapy with persistent mild proteinuria at <500 mg/g at 6 months. Dual MPO and PR3 positivity persisted until Rituximab completion, after which only MPO positivity continued.

Discussion

It is well known that anti-thyroid medications can cause drug-induced AAV. However, this renal limited AAV case with desiccated thyroid supplementation suggests clinicians should also be aware of AAV as a possible adverse consequence of thyroid supplementation. Management should include discontinuation of the offending agent and consideration of immunosuppression with standard induction regimens based on disease severity.